Claremont Retirement Village

Based on observation, staff interview, and record review, the facility failed to ensure food was stored in a safe and sanitary manner and failed to store the kitchen equipment in a sanitary manner. This had potential to affect all 51 residents who receive food from the kitchen.

Findings include

1. Observation on 02/05/25 at 10:40 A.M. revealed in the dry storage area, two cans (mandarin oranges and olives) had large dents and were on the for use shelf. An opened bag of dried pasta shells, pecans, almonds, shredded coconut, two bags of vanilla wafers, and a bag of oreos were undated. A box of cake mix and a bag of tortillas were left open to air and undated. In the refrigerator, a bag of blue cheese had a date sticker that was left blank, a bag of shredded white cheese, a metal dish of orange cheese, a one-fourth ham hock and a baggie of whipped cream were open and undated. In the freezer, there was a bag of cookie dough, a tray of flaky dessert, waffles, two packs of garlic toast, three bags of vegetables (green beans), and two packs of bagels were undated and the chicken and waffles were left open to air with two waffles that had fallen onto other food items from its open container. Facility also had a cart with several trays of desserts left uncovered in the kitchen prep area and no staff were observed to be plating desserts at this time.

Interview on 02/05/25 at 10:53 A.M. with Kitchen Manager #101 confirmed food should be labeled and dated with the received date and opened date and items should be closed or secured in packaging. KM #101 confirmed the findings of food food items found open and undated in the dry storage, refrigerator and freezer.

2. Observation and interview on 02/05/25 at 11:00 A.M. with Cook #161 revealed the ice scoop was sitting in the ice machine in the pile of ice. A metal scoop holder was observed inside the ice box without the scoop being held. Cook #161 confirmed the ice scoop should be held in the scoop holder.

Review of facility policy titled, Infection Control for Food Service Department

Based on observation, staff interviews, and record review, the facility failed to ensure puree foods were made to an accurate consistency. This had the potential to affect two residents (#44 and #56) the facility identified who were on puree diets. The facility census was 51.

Findings include:

1. Review of the medical record for Resident #44 revealed an admission date of 01/11/23. Diagnoses included Alzheimer's disease, heart disease, and muscle weakness.

Review of the physician orders for Resident #44 revealed an order dated 11/05/24 for a puree diet.

2. Review of the medical record for Resident #56 revealed an admission date of 01/12/23. Diagnoses included malignant neoplasm of breast, vitamin deficiency, dementia without having behaviors, and Alzheimer's disease.

Review of the physician orders for Resident #56 revealed an order dated 07/18/24 for a puree diet.

Observation on 02/05/25 at 11:25 A.M. revealed Cook #145 made puree turkey tettrazini and peas for two residents (#44 and #56). Two one-cup scoops were placed in roboku mixer along with three-fourths cup of water and blended. Cook #145 then poured the mixture into two bowls. The mixture filled the bowls and did not hold a form. The mixture splashed on the edges and sides of the bowl. The mixture was tasted and small pieces of vegetables were able to be distinguished from the mixture. Cook #145 said the mixture was okay and planned to serve it as is. Cook #145 then made pureed peas by adding two-half cup servings of peas and half cup of water into roboku mixer and blended together. When Cook #145 was done, he poured the mixture into bowls. Food was then tasted and pieces of the skin from the peas could be distinguished. The food also was liquid in texture and filled the bowl without taking form.

Interview on 02/05/25 at 11:30 A.M. with Cook #145 revealed staff were looking for a liquid consistency for puree and confirmed food did not hold a scoop form. He revealed no recipe or instruction was available when making puree foods.

Interview on 02/05/25 at 1:56 P.M. with Registered Dietitian (RD) #400 confirmed facility should not use water to make puree as it dilutes the nutritional value of the food. They should be following the instructions or recipe and start with the item and add a thinning agent (sauce broth etc.) or thickener to adjust the food as needed. RD #400 confirmed puree food should hold a form and not fill in the plate or bowl shape when served.

Review of the facility policy titled Therapeutic diets dated 05/03/23 revealed special diets shall be offered in compliance with state regulations and provided according to physician order. Director of Dining Services shall oversee all training for all cooks, servers, and kitchen staff.

Review of the facility's undated policy titled Mechanically Altered Diets revealed mechanically altered diets shall be prepared and served as prescribed by the physician. For puree diets, food shall be pudding like with no corse texture or raw foods were allowed.

Based on record review and staff interview, the facility failed to ensure fire drills were conducted at least once each shift every three months, failed to provide evidence of resident evacuations and verification of receipt of the fire alarm signal timely, and failed to ensure all staff participated in at least one fire drill yearly. This had the potential to affect all 51 residents residing at the facility.

Findings include:

Review of the fire drill documentation from 02/25/24 to 01/17/25 revealed there was no evidence of resident evacuations and no verification of receipt of the fire alarm signal by the security company or 911 during the time period which included the following dates: 02/25/24, 03/26/24, 04/18/24, 05/11/24, 06/27/24, 07/30/24, 08/08/24, 09/12/24, 10/14/24, 11/21/24, 12/18/24, and 01/17/25.

The facility did not completed an evening/night shift fire drills. Drills occurred day shifts on 06/27/24 at 2:00 P.M., 07/30/24 at 8:45 A.M., and 08/08/24 at 1:30 P.M.

There was no evidence of all staff participating in at least one annual fire drill.

Interviews on 02/05/25 on 1:04 P.M. and 3:37 P.M. with the Executive Director (ED) and Director of Operations (DOO) #133 confirmed no documented evidence that residents were evacuated in fire drills, and also confirmed facility does not have verification of receipt of the fire alarm either by security company or 911. The ED and DOO #133 confirmed the facility went three months without a second or third shift fire drill. The ED stated staff work two-12 hour shifts from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. The ED and DOO #133 confirmed the facility did not have evidence all staff participating in at least one fire drill in the past year.

Review of the facility's Fire and Safety policy and procedure dated 05/21/23 revealed the community will hold a fire drill each month, rotating through both shifts within each quarter.

Based on record review and interview, the facility failed to ensure fire drill documentation contained all required information, method of activation, effectiveness of drill procedures, and number of individuals evacuated in the facility. This had the potential to affect all 51 residents residing at the facility.

Findings include:

Review of the fire drill documentation from 02/2024 to 01/2025 revealed the facility did not include the method of activation, the effectiveness of drill procedures, and the number of individuals evacuated were not included on their fire drills. The fire drills were completed on 02/25/24, 03/26/24, 04/18/24, 05/11/24, 06/27/24, 07/30/24, 08/08/24, 09/12/24, 10/14/24, 11/21/24, 12/18/24, and 01/17/25.

Interviews on 02/05/25 on 1:04 P.M. and 3:37 P.M. with Executive Director and Director of Operations (DOO) #133 confirmed fire drill documentation did not include method of activation, effectiveness of drill procedures, and number of individuals evacuated in the facility.

Based on medical record review, review of electronic mail (email) documents, review of a self-reported incident (SRI), staff interview, and policy review, the facility failed to timely investigate an allegation of misappropriation. This affected one (#12) of seven residents reviewed for misappropriation. The census was 48. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/12/23. Diagnoses included depression, anxiety, polyneuropathy, and osteoarthritis. Review of an email on 07/15/24 from Resident #12's Power of Attorney (POA) to the Executive Director (ED) reported Resident #12's bank card was used for unauthorized purchases. The POA suggested two employees of the facility could have used the card without permission. Review of an email dated 09/14/24 revealed the ED was notified by Resident #12's POA concerning a purchase of $62.54 made by an employee of the facility. The facility initiated an SRI on 09/16/24 for alleged misappropriation. Review of the SRI dated 09/16/24 revealed the allegation of misappropriation on 09/14/24 was investigated but made no mention that the ED or an assigned employee investigated the allegation from 07/15/24 when Resident #12's POA sent an email to the ED about Resident #12's bank card being use for unauthorized purposes. Further review of the facility SRIs revealed no evidence of an investigation completed for the allegation on 07/15/24. Interview on 09/23/24 at 10:00 A.M. with the ED revealed he received an email on 07/15/24 from Resident #12's POA reporting Resident #12's bank card was used for unauthorized purchases, and suspected two employees of the facility could have used the card without permission. The ED verified he did not conduct an investigation for misappropriation of Resident #12's funds via unauthorized use of SR #12's bank card on 07/15/24. Interview on 09/24/24, at 3:57 P. M. with Business Office Manager (BOM) #135 confirmed Resident #12's bank card and checkbook were brought to her office and placed in a safe on 07/15/24 the POA's request, and verified she was never investigated about unauthorized use of Resident #12's bank card by any employee of the facility. Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of Property (ANM) Policy and ProcedureBased on medical record review, review of electronic mail (email) documents, review of a self-reported incident (SRI), staff interview, and policy review, the facility failed to timely investigate an allegation of misappropriation. This affected one (#12) of seven residents reviewed for misappropriation. The census was 48.

Findings include:

Review of the medical record for Resident #12 revealed an admission date of 01/12/23. Diagnoses included depression, anxiety, polyneuropathy, and osteoarthritis.

Review of an email on 07/15/24 from Resident #12's Power of Attorney (POA) to the Executive Director (ED) reported Resident #12's bank card was used for unauthorized purchases. The POA suggested two employees of the facility could have used the card without permission.

Review of an email dated 09/14/24 revealed the ED was notified by Resident #12's POA concerning a purchase of $62.54 made by an employee of the facility. The facility initiated an SRI on 09/16/24 for alleged misappropriation.

Review of the SRI dated 09/16/24 revealed the allegation of misappropriation on 09/14/24 was investigated but made no mention that the ED or an assigned employee investigated the allegation from 07/15/24 when Resident #12's POA sent an email to the ED about Resident #12's bank card being use for unauthorized purposes. Further review of the facility SRIs revealed no evidence of an investigation completed for the allegation on 07/15/24.

Interview on 09/23/24 at 10:00 A.M. with the ED revealed he received an email on 07/15/24 from Resident #12's POA reporting Resident #12's bank card was used for unauthorized purchases, and suspected two employees of the facility could have used the card without permission. The ED verified he did not conduct an investigation for misappropriation of Resident #12's funds via unauthorized use of SR #12's bank card on 07/15/24.

Interview on 09/24/24, at 3:57 P. M. with Business Office Manager (BOM) #135 confirmed Resident #12's bank card and checkbook were brought to her office and placed in a safe on 07/15/24 the POA's request, and verified she was never investigated about unauthorized use of Resident #12's bank card by any employee of the facility.

Review of the undated facility policy titled, Abuse, Neglect, Misappropriation of Property (ANM) Policy and Procedure

Based on observation, interview and facility policy review, the facility failed to ensure food was stored and prepared in a manner that protects it from contamination or spoilage. This had the potential to affect all 50 residents in the facility who receive meals from the kitchen. The census was 50.

Findings include:

1. Observation on 01/17/23 from 8:25 A.M. to 8:28 A.M. revealed Dining Services Staff #75 was not wearing a hairnet in order to restrain his hair while preparing food behind the preparation table in front of the range. The observation revealed there was a sign posted in the kitchen next to the hand washing sink which stated Wear Hair Restraints and Hairnets, Enforced.

Interview on 01/17/24 at 8:28 A.M., with Dining Services Staff #75 confirmed he was not wearing a hair restraint while in the food preparation area.

Review of the facility policy titled Dining Department Infection Control Policy

Based on medical record review, review of an Emergency Medical Services (EMS) report, review of facility video camera footage, review of the weather information at https://www.timeanddate.com/weather/usa/columbus, staff interview, resident representative interview, and facility policy review, the facility failed to ensure one resident (#27) was provided a safe environment and adequate supervision to prevent elopements. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death, when Resident #27, who was cognitively impaired, had a history of exit seeking behaviors, and was at high risk for elopement, eloped from the facility during the early morning hours on 02/09/23. Resident #27 was found by a good Samaritan on his hands and knees in the grass near the facility and the good Samaritan called emergency medical services (EMS) on 02/09/23 at 1:48 A.M.. EMS arrived at 1:57 A.M. and found Resident #27 shivering and confused with a body temperature of 94.7 degrees Fahrenheit (F). EMS treated Resident #27 for hypothermia and transported Resident #27 to the nearest hospital. The temperature outside on 02/09/23 around 1:51 A.M. was 45 degrees Fahrenheit (F) and overcast. This affected one resident (#27) out of three residents reviewed for wandering and elopement. The facility census was 47.

On 02/15/23 at 3:06 P.M., Executive Director (ED) #93 and Director of Operations (DOO) #58 were notified Real and Present Danger began on 02/09/23 at approximately 1:48 A.M. when Resident #27 was found a good Samaritan on his hands and knees in the grass near the facility. EMS arrived on the scene and found Resident #27 shivering with a body temperature of 94.7 degrees Fahrenheit (F). EMS treated Resident #27 for hypothermia and transported Resident #27 to the nearest hospital.

The Real and Present Danger was abated on 02/17/23 when the facility implemented the following corrective actions:

On 02/15/23 the elopement risk assessment totals for the current resident population in Assisted Living were as follows:

Minimum Risk: 25

Moderate Risk: six

High Risk: one (Resident #27 who was currently in the hospital)

On 02/15/23, Director of Operations #58 updated the lease agreement for all new admissions to the Assisted Living and contains the following language under section 5.1.4. The facility assesses each Assisted Living resident for a risk of elopement upon admission and on a quarterly basis thereafter.

On 02/15/23, the Executive Director educated all dayshift Assisted Living care staff members, who were currently on site at the facility, on the Elopement Policy and the staff signed a document indicating they received the education.

On 02/15/23 at 7:00 P.M., the nightshift Assisted Living care staff member who were coming on to their shift received education by the Executive Director on the Elopement Policy and signed a document indicating they received the education.

On 02/15/23 at 8:00 P.M., Director of Operations #58 added alarms to the exit doors on the hallways of the Assisted Living. The exit doors alarm at a central monitoring station in the Assisted Living whenever they are opened and alert staff members on duty to check/investigate the door.

On 02/15/23 before 10:00 P.M., the elopement policy was sent via email by Director of Operations #58 to all Assisted Living care staff members who were not on site and were not scheduled to work in the upcoming 24 hours. Additionally, all Assisted Living care staff members were required to sign electronically that they read and understood the elopement policy before 02/17/23 at 5:00 P.M.

All elopement risk assessments for current residents in the Assisted Living will be reviewed by the Executive Director and Director of Nursing (DON) #60 for accuracy by 02/16/23 no later than 3:00 P.M.

On 02/16/23, the Executive Director and DON #60 completed a review of all elopement risk assessments of current residents to ensure accuracy. No residents had any changes on the elopement risk assessments, aside from Resident #28, who scored as high risk for elopement. Resident #28 was issued a 30-day move out notice on 02/16/23 as his clinical care needs exceed the facilities abilities, in addition to his increased elopement risk. During the 30-day period that Resident #28 remains in the facility, care staff will perform hourly visual checks to ensure the safety of Resident #28.

On 02/16/23, the Executive Director issued a 30-day move out notice to Resident #27 in accordance with the signed lease agreement from 11/24/2018, section V, paragraph B, lines 1 and 3: Resident shall not be transferred or discharged from the community except: 1. If the welfare and needs of the resident cannot be met. 2. If the resident's health or safety and/or health or safety of others in the home is endangered.

On 02/16/23 by 5:00 P.M., the Director of Operations #58 created an addendum to the current signed lease agreement for all Assisted Living residents was sent to the responsible party/Power of Attorney (POA) of each resident and contained the following language and required signature: the facility assesses each Assisted Living resident for a risk of elopement upon admission and on a quarterly basis thereafter. Should the resident receive a Moderate score, the responsible party/POA will be notified. No further action will be necessary at that time. Should the resident receive a high score, the responsible party/POA will be notified immediately and informed of the need to transfer the resident to the CRV secure Memory Care Unit. Should there be no available room in the CRV Memory Care unit or the responsible party/POA refuses the transfer, CRV will issue a 30-day move out notice. This addendum must be signed and returned to CRV within 30 days of receipt. This addendum will become part of the official lease agreement. Failure to comply will result in termination of the residency agreement and issuance of a 30-day move-out notice.

On 02/16/23 by 3:00 P.M., the Executive Director completed the following for all current residents who scored as a high risk on the elopement assessment: The responsible party/POA was notified immediately of the score of the assessment. The responsible party/POA was advised of the need to transfer the resident to the secure Memory Care (MC) unit within 24 hours and if the MC unit did not have any space for a new admission at that time and/or the responsible party/POA refused to agree to the transfer and/or the resident's care needs exceed the facilities abilities, then a 30-day move-out notice would be issued.

On 02/16/23, Wandering and Elopement: A Comprehensive Review course was added by Director of Operations #58 to the new hire orientation learning. Completed 02/16/23 by Director of Operations.

On 02/16/23, the Service Plans for all Assisted Living residents were reviewed by the DON #60 to assess for any changes in needs and associated provision of care by the facility. There were no changes in service plans except for Resident #28.

Observations on 02/16/23 with Director of Operations (DOO) #58 of the exit doors on the Assisted Living revealed the doors had silent alarms in place that alerted to the computer station in the dining room/outside of the nurse's station/charting room. The alert had to be cleared out by a staff person in order to turn off the alert.

Interviews on 02/16/23 with State Tested Nurse Aide (STNA) #72, DON #60, and Licensed Practical Nurse (LPN) #79 verified they had been educated on elopement policies and were knowledgeable about the procedures.

By 02/17/23 at 5:00 P.M., all Assisted Living care staff members signed electronically that they read and understood the elopement policy.

The DON #60 will complete an Elopement Risk Assessment on all Assisted Living residents on a monthly basis beginning 03/01/22 for two months and then revert to the original plan on a quarterly basis.

The Director of Operations #58 will conduct monthly audits of staff training modules through the online education system the facility employs, to ensure that staff remain compliant and up to date with all necessary training and education. The monthly audits will begin in March 2023 and will be conducted once per month.

The DON #60 will review the interventions on the Assisted Living residents care plans on a quarterly basis to ensure accuracy and appropriateness.

Although the Real and Present Danger was abated on 02/17/23, the violation remains as the facility was in the process of monitoring and implementing their correction actions.

Findings include:

Review of the medical record for Resident #27 revealed an admission date of 11/26/18. Resident #27's diagnoses included dementia, depression, macular degeneration, history of falling, and unsteady gait.

Review of the History and Physical Form, dated 09/30/22, revealed Resident #27 had dementia and an unsteady gait.

Review of the Elopement Risk Assessment, dated 10/25/22, revealed Resident #27 was a high risk for elopement. Resident #27 wandered the community, displayed agitation and increased anxiety in the afternoon, frequently required redirection on location, was disoriented daily, was ambulatory with a medical diagnosis of dementia, and received antipsychotic and hypnotic medications. Interventions on Resident #27's service plan included: one to one, redirection, offer food and drink, offer to rest or nap, notify the physician, hospice provider, and Power of Attorney (POA), and administer as needed (PRN) medications.

Review of Resident #27's progress note, dated 10/26/22 at 2:00 P.M., revealed Resident #27 continued with agitation, confusion, and delusions intermittently as well as nights of insomnia. The nurse was notified by care staff that Resident #27 was exit seeking at approximately 12:30 A.M.

Review of Resident #27's progress note, dated 02/09/23 at 9:30 A.M., revealed Resident #27 wandered outside in the early morning and was picked up and taken to a local hospital.

Review of Resident #27's progress note, dated 02/09/23 at 10:30 A.M., revealed LPN #79 documented Power of Attorney (POA) #85 indicated Resident #27 was admitted to the hospital related to hypothermia.

Review of Resident #27's progress note, dated 02/09/23 at 1:00 P.M., revealed a return call from POA #85 was received and POA #85 informed the facility Resident #27 was found by a good Samaritan while walking outside in an unknown location and called 911. Resident #27 was transported to the hospital.

Review of the EMS report, dated 02/09/23, revealed Resident #27 was found at 1:57 A.M. seated in the passenger seat of a good Samaritan's vehicle. The good Samaritan found Resident #27 on his hands and knees in the grass near the facility. Resident #27 was shivering and confused with an oral body temperature of 94.7 degrees F. Resident #27 stated he was very cold. Resident #27's vital signs showed an elevated blood pressure of 150/90 and a pulse of 120 beats per minute (bpm). Resident #27's wet clothing was removed to facilitate warming. Resident #27 was treated for hypothermia by the EMS and transported to the local hospital.

Review of the weather information at https://www.timeanddate.com/weather/usa/columbus revealed the temperature outside on 02/09/23 at 12:51 A.M. was 43 degrees F with rain and fog, and on 02/09/23 at 1:51 A.M. the temperature was 45 degrees F and overcast.

Interview on 02/14/23 at 11:25 A.M. with STNA #72 revealed Resident #27 was found outside and taken to the hospital. The interview further revealed Resident #27 remained in the hospital at the time of the interview. STNA #72 stated Resident #27 was confused and wandered around the facility. STNA #72 stated there were no alarms on the assisted living exit doors in order to alert staff when a door was opened.

Observation on 02/14/23 at 11:25 A.M. with STNA #72 of the exit doors in the Assisted Living confirmed there were no alarms when the exit doors were opened.

Interview via telephone on 02/14/23 at 12:10 P.M. with Security (SEC) #68 revealed she was working security for the facility during the night shift on 02/09/23 when she received a phone call in the early morning from Resident #27's daughter requesting someone check on Resident #27 because she had been trying to reach him without success which was unusual for that time of the morning. SEC #68 agreed and checked Resident #27's room but the resident was not found in his room. SEC #68 and Caregiver (CG) #63 began searching for Resident #27. Resident #27's daughter called back to report they could stop searching for the resident because he was at the hospital after being found outside by a good Samaritan. SEC #68 stated Resident #27 wandered all over. SEC #68 confirmed the exit doors in the Assisted Living do not alarm because the residents are totally independent. SEC #68 stated Resident #27 was exit seeking and reported she had gone after him many times before in order to redirect him back into the facility. SEC #68 stated Resident #27 was always very confused and got agitated.

Interview on 02/14/23 at 1:05 P.M. with DON #60 revealed Caregiver #63 was the only staff member scheduled during night shift on 02/09/23.

Interview on 02/14/23 at 1:18 P.M. via telephone with Caregiver (CG) #63 confirmed she was the only staff member on duty for the assisted living during night shift on 02/09/23. CG #63 reported she had seen Resident #27 at approximately 7:30 P.M. and 8:00 P.M. wandering in the hallway around another resident's room. At approximately 9:30 P.M., CG #63 observed Resident #27 again in the hallway and redirected the resident back to his room. CG #63 stated she last checked on Resident #27 around midnight on 02/09/23 and he was in laying in his bed at that time.

Interview on 02/14/23 at 3:18 P.M. via telephone with POA #85 revealed he had received a phone call from the hospital on 02/09/23 at approximately 5:30 A.M. informing him Resident #27 was seen by a good Samaritan outside of the assisted living facility and the good Samaritan called 911. EMS transported Resident #27 to the hospital with a below normal temperature and an elevated pulse between 120 and 130 bpm. POA #85 stated the facility was not aware Resident #27 had wandered outside. POA #85 stated he was informed by the facility around December 2022 that they were trying their best to keep him (Resident #27) out of the Memory Care Unit and had started Seroquel medication because he was not sleeping at night. POA #85 stated he was not made aware that Resident #27 was displaying wandering behavior or that he was confused. POA #85 stated he was only aware Resident #27 got agitated at times.

Interview on 02/14/23 at 4:04 P.M. with LPN #79 revealed Resident #27 was usually confused in the evening hours.

Review of the camera footage with DOO #58 revealed on 02/09/23 at 6:10 P.M. and at 6:13 P.M, Resident #27 was wandering in the hallway and was wandering towards three different resident rooms. Resident #27 required redirection from the facility staff to return to his room.

Interview on 02/15/23 at 10:50 A.M. with Executive Director (ED) #93 and DOO #58 confirmed Resident #27 had a history of wandering around the facility and was identified as a high elopement risk prior to the incident on 02/09/23. ED #93 also confirmed there was no follow up documented with POA #85 after October 2022 in order to discuss a possible move to the Memory Care Unit when the resident's wandering, confusion, and agitation had increased. ED #93 and DOO #58 confirmed the doors in the assisted living did not alarm or alert staff when they were opened. ED #93 and DOO #58 confirmed Resident #27 eloped without staff knowledge on 02/09/23.

Review of the facility policy titled Elopement Policy